In this chapter

Building Upon Existing Jail Efforts

EnhanceLink grantees who expanded current jail work focused the bulk of their monies on expanding case management services and relinking clients to care and social services. Some sites had relationships with their jail but were not doing formal linkage work prior to the EnhanceLink initiative. Even without extra money like a grant, there are small steps a community provider can take to improve jail linkage work, such as assessing the existing system and streamlining the process to reduce any redundancies or devoting a proportion of an outreach worker’s time to the jail. In examining your work, you may find a disproportionate delivery of services to clients. Consider pooling resources and creating a centralized and accountable way to track patient outcomes.

Recognize that growing your program requires flexibility. There may be growing pains due to the volume of new HIV-positive clients that stretches your original model capacity.3

Tips to Remember

Jails are locally managed so they can vary a lot across a single State. Just because you may be working with one jail doesn’t mean there’s not a learning curve to starting a new relationship and working process within another.

Remember that jails have high staff turnover so educational sessions and relationship building needs to be continuously revisited.

Whether with the jail, your partners, or the inmates you’re working with, keep your promises.

How can organizations maintain partnerships?

Don’t take partnerships for granted. They need continuous nurturing. Even formalized, longstanding relationships may require moving beyond referrals to creating contracts or formally listing partners as subcontractors on a grant.

Ongoing communication and collaborative case conferencing are important for partnering organizations, as they reduce duplication, improve teamwork and communication, provide transparency, and enable any programmatic issues to be identified and addressed early on. Care should be coordinated with partners with a clear understanding of how to track patients, such as a universal client interview tool to facilitate the sharing of complete health information and outcomes. If you haven’t already, consider creating a procedures manual outlining who is responsible for what and referral policies; all players should review and approve the manual.

Your relationship with the jail is essential, and any changes to or expansion upon your services to inmates must be communicated with jail officials. Be respectful of jail staff, as well as the top-down hierarchy within the setting you’re working. Jail administrators’ continuous buy-in is essential to this work. Be courteous; you’re working in their space. Leave things how you found them.35

How can organizations assess patient needs?

Work needs to be done quickly with inmates since jail stays may be brief and discharge dates may be unknown or in flux. As soon as they’re identified as HIV positive, inmates should be met and undergo a needs assessment. Remember to always ask first if someone has tested positive for HIV; the majority of EnhanceLink participants knew their status but were out of care.

HIV. For the newly diagnosed HIV-positive inmates, work to educate them about HIV, help mitigate fears, and tell them about your organization’s resources. For known positives, work on reengagement in care. Reengagement in care means working with the individual’s priorities and mutually setting goals; this can assist in a feeling of empowerment and help with buy-in.

- Ongoing in the jail: provide risk-reduction education. Many EnhanceLink grantee sites offered a series of classes on HIV, sexually transmitted infections, hepatitis, tuberculosis, prevention, and strategies for dealing with emotional issues. (See “Risk-Reduction Education” in the associated training manual.) A template with educational session protocols and a health education quiz are included in the back of this guide.

Substance abuse. Let inmates know you are not here to judge. Recognize that not all inmates with substance abuse issues are ready or willing to seek treatment.

Relationships. Many inmates have destructive relationships. It is important to ask questions, listen, and try to provide support. Try to talk to inmates about this and healthy ways of dealing with stress.36

Mental health. Try to identify a community partner with counseling services; underscore the benefits of support groups. If there’s a mental health organization working within the jail or a psychologist on staff in the jail, bring them on board. Recognize, however, that current mental health services in the jail may be focused on more serious conditions (e.g., schizophrenia) and less so on emotional disorders.

Housing. Housing is a huge need among this population. Don’t make assumptions, however. Some inmates may have greater support networks and, thus, more post-release housing options than others.

Work and benefits. For some patients, their sense of identity and self-esteem is tied to their ability to hold a job. Many inmates are men, and work may be very central to their sense of identity and accomplishment.37

Court advocacy. Your organization may not be able to provide much, or any, court advocacy. Remember, however, that there are a lot of organizations that assist folks with getting into drug treatment as opposed to continuing on to incarceration.38 “In order to convince the judges and in order to make an appropriate placement, they had a need for health assessment and medical documentation, and so health advocates or health liaisons to the courts have been able to help the court facilitate the placement and alternatives to incarceration by being the conduit between the person’s medical information, and so they have the information they need to get people accepted into programs.”39 Don’t overpromise inmates that this will take place, but do remember to get permission to advocate on their behalf and share medical and substance abuse history information.

Figure 1: Most Common Case Management-Collected Data

When providing care coordination, the majority of grantee sites asked open-ended questions and greeted inmates with a warm smile and handshake. When incentives were provided, the most common was in the form of transportation assistance, followed by clothing items and then gift cards.

What to keep in mind when creating a discharge plan

Barriers to care and competing needs prior to incarceration still exist post-release unless case management and linkage to necessary support and health care services can be established.40 In fact, exposure to risk and relapse can occur overnight as inmates move from a controlled environment back into the community.41 Without the appropriate skills and support, it’s easy to understand why individuals fall immediately back into the behaviors that got then arrested in the first place.

To help address inmates’ health and social support needs upon release, the most common areas addressed in discharge planning included medication adherence; substance abuse or alcohol treatment; primary HIV care and managing their disease; social services and other entitlements; housing assistance and transitional housing; mental health treatment; intensive outpatient day treatment (or prescription); health insurance; and court advocacy.42

Meet with inmates before release and create their discharge plan. Things to keep in mind regarding the discharge date:

Recognize that relationships with jail staff are essential for discharge coordination.

Talk to inmates; they might have a good sense for if they’re being released and, perhaps, when.

If discharge date is known, schedule appointments before discharge.

Realize that some inmates get released very quickly, so a lot of intensive case management may happen after release.43

Prepare for both scenarios, whether the client is released or not.

Build in a contingency aspect to your plan if inmates are released early and you are not able to meet them at release. This includes providing inmates with a copy of their plan ahead of time. Provide inmates with list of community resources and a number (preferably toll-free) to call if they encounter challenges.

When you are creating a discharge plan, the inmate has to be on board with those steps and resources you are proposing. Talk about their priorities and really listen. Recognize that sometimes inmates are wildly unrealistic, so it is important to work with them to set realistic goals and steps. This includes managing patient expectations of what you are able to provide. If realistic goals are met, then they’ll feel a sense of accomplishment and positive reinforcement. If goals are unrealistic, when they’re not met people are more apt to spiral and relapse.44

Case managers might have big plans, but if the community options don’t exist then they’re setting up patients to fail; case managers must be attuned to the community. That’s why an understanding of what’s available and where to get it is essential in drafting a patient’s discharge plan.45 Sometimes meeting an individual’s needs means having a “scrappy” approach and pulling in resources wherever you can.

Important aspects of a discharge plan include:

Addressing inmates’ basic needs.

– This includes housing (whether transitional housing, subsidized housing, the Salvation Army, or a shelter, depending on your community resources). Housing is a very real need and a big barrier to care.

– Don’t forget about food. Many EnhanceLink sites were surprised how big an issue hunger was.

Don’t forget about incentives. Most common in the EnhanceLink work were transportation assistance and clothing.

Recognize, however, that addiction is a relapsing disorder and that not all inmates with addiction are ready or willing to tackle this.

Communicate with community partners and know the logistics of linkage to care and case finding steps, including collecting locator information so that you can find individuals post-release.

– This includes information such as legal name; aliases/street name; date of birth; Social Security number; identifying information (e.g., tattoos); address if they have one or family member address; phone number or ways to reach them, including emergency contact information; and places they like to hang out (e.g., barber shop).

– Ensure you receive permission to reach out to them.

– See Templates to view an example of a locator information template.

Things to consider on the day of discharge include:

Ensuring releasees have a copy of their discharge plan.

Providing a prescription, medications, or “blister packs” if possible. (Note, this may be dependent on how long the patient has been in the jail facility; for some patients, they may access antiretrovirals [ARVs] post-incarceration due to time detained.)

Meeting patients as they are released or shortly thereafter (as soon as possible).

Releasing individuals with transportation assistance and/or at hours when public transit is running (i.e., don’t set up people to fail).

Finding Positive Reinforcements

“We always ask, ‘What’s helped you in the past?’ This assists in linking them back to positive influences. If they’ve stayed clean and out of jail before, what was going on during that time? Was it work, church, were they living with their mother? Case managers need to be willing to talk about whatever it is in the community that has a positive influence.”

—Dr. Timothy Flanigan, Miriam Hospital, EnhanceLink grantee

Linking releasees to services: What to consider

When HIV-positive individuals are being released from jail, they may not have had long to think about how they ended up incarcerated and “may be less inclined to cooperate with treatment plans and may be less motivated to change the behaviors that put them in jail and put their health at risk. This attitude means that for the jail linkage program, the hardest work starts when a client’s jail sentence ends.”46

“Paper referrals are a process, not an outcome,” says one EnhanceLink grantee. Actively link releasees to services as outlined in their discharge plan. Accompany releasees to their first appointment and have a “warm transition” or “soft handoff.”

Arrange to have releasees seen for HIV primary care as soon as possible after discharge. This may include educating front desk staff that these individuals are to be worked into the schedule whenever they arrive, or during walk-in clinic hours.

Many releasees will need assistance securing IDs and working through paperwork to qualify for benefits; in addition, they may not be used to processes such as waiting in line and will need guidance on this and when to expect benefits to “kick in.” You or the Ryan White case manager may have begun this process once a discharge date was known or you may begin this process post-release.

In addition to linking to social support needs, also consider linking patients to community job training resources and organizations that hire ex-offenders if available in your community.

Realize that it takes a certain kind of staffer and a fair amount of resiliency to work with challenging populations. As such, be flexible in both case management and in referrals because the “miss one appointment and you’re out” mentality doesn’t work with this population.

Recidivism is real. Despite your best efforts, this will likely happen with some releasees. This means when individuals don’t show up for appointments and can’t be reached, one place to look is the jail. It also means that you may see the same people in a jail setting more than once and you need to be nonjudgmental when you reach out and seek to reengage and relink them.47

Take home messages

Even in a brief amount of time, you can do meaningful case management.

A break in linkage to care is not inevitable.

Discharge planning is necessary.

It is important to hire people for case management who are dedicated to this work.

It’s a team effort and you need an able leader.

You have to be specific in job descriptions and devote resources and time.

This work is cost-effective.

Source: Spaulding A. Emory University Rollins School of Public Health. December 2012. [Personal interview.]